Diabetes Self Management Training

Medicare covers diabetes outpatient self-management training when furnished by a certified provider who meets certain quality standards. A diabetes outpatient self-management training (DSMT) program includes education about self-monitoring of blood glucose, diet/ exercise, an insulin treatment plan developed specifically for the patient who is insulin-dependent, and motivation for patients to use the skills for self-management. The following is a guide explaining Medicare coverage requirements.

Beneficiaries Eligible for Coverage

Medicare Part B covers (not to exceed) 10 hours of initial training for a beneficiary who has been diagnosed with diabetes. Diabetes self-management training may be covered by Medicare if the physician or qualified non-physician practitioner who is managing the beneficiary’s diabetes certifies that such services are needed. The order must also include a statement signed by the physician that the service is needed as well as the following:

· the number of initial or follow-up hours ordered (the physician can order less than 10 hours of training);

· the topics to be covered in training (initial training hours can be used for the full initial training program or specific areas such as nutrition or insulin training);

· a determination that the beneficiary should receive individual or group training; and

· the provider of the service must maintain documentation in a file that includes the original order from the physician and any special conditions noted by the physician.

Frequency of Training-Initial Training

The initial year for DSMT is the 12 month period following the initial diagnosis. Medicare will cover initial training that meets the following conditions:

· is furnished to a beneficiary who has not previously received initial or follow-up training under HCPCS codes G0108 or G0109;

· is furnished within a continuous 12-month period;

· Does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of 1/2 hour increments);

· with the exception of 1 hour of individual training, training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries; and

· one hour of individual training may be used for any part of the training including insulin training.

Follow-Up Training

Medicare covers follow-up training under the following conditions:

· no more than 2 hours individual or group training per beneficiary per year;

· group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;

· follow-up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;

· follow-up training is furnished in increments of no less than one-half hour; and

· the physician (or qualified non-physician practitioner) treating the beneficiary must document in the beneficiary's medical record that the beneficiary is a diabetic.

Coverage Requirements for Individual Training

Medicare covers training on an individual basis for a Medicare beneficiary under any of the following conditions:

· no group session is available within 2 months of the date the training is ordered;

· the beneficiary’s physician (or qualified non-physician practitioner) documents in the beneficiary’s medical record that the beneficiary has special needs resulting from conditions, such as severe vision, hearing or language limitations or other such special conditions as identified by the treating physician or non-physician practitioner, that will hinder effective participation in a group training session;

· the physician orders additional insulin training; or

· the need for individual training is identified by the physician or non-physician practitioner in the referral.

CPT codes for DSMT

Suppliers/providers who bill other Medicare services or items and who represent a DSMT program that is accredited as meeting quality standards can bill and receive payment for the DSMT program under the following HCPCS codes:

· G0108 Diabetes outpatient self-management training service, individual, per 30 minutes.

· G0109 Diabetes outpatient self-management training services, group session, (two or more), per 30 minutes.

Written by Patty Curoe Telgener, RN, MBA

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